Healthcare Provider Details

I. General information

NPI: 1487955589
Provider Name (Legal Business Name): NICOLE EVE FAYARD LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2010
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19662 WOOTTON AVE SUITE 203
POOLESVILLE MD
20837-3003
US

IV. Provider business mailing address

19662 WOOTTON AVE SUITE 203
POOLESVILLE MD
20837-3003
US

V. Phone/Fax

Practice location:
  • Phone: 240-271-7689
  • Fax:
Mailing address:
  • Phone: 240-271-7689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLC3474
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: